1、Chi Feng University Chai Nan Chi Feng University Chai Nan NanNan Integrated Health AssessmentCase Study“患者女性，患者女性，2222歲，因反復(fù)咽痛歲，因反復(fù)咽痛4 4個月，胃寒，高個月，胃寒，高熱熱2 2天入院，最高體溫可達天入院，最高體溫可達39.839.8C C。急診以。急診以“發(fā)熱發(fā)熱待診待診”收入院。入院收入院。入院T39.2T39.2C C，P124P124次次/ /分，分，R24R24次次/ /分，分，BP90/70mmHgBP90/70mmHg?；颊甙l(fā)育正常?；颊甙l(fā)育正常, ,

2、營養(yǎng)良好營養(yǎng)良好, ,意意識清晰識清晰, ,面色潮紅面色潮紅, ,全身淺表淋巴結(jié)未觸及全身淺表淋巴結(jié)未觸及, ,咽紅咽紅, ,兩肺未聞及啰音兩肺未聞及啰音, ,心臟未聞及病理性雜音心臟未聞及病理性雜音, ,患者自患者自患病以來焦慮不安患病以來焦慮不安, ,睡眠差睡眠差, ,希望了解病情希望了解病情, ,得到治得到治療。療?！盡edical care and nursingMedical DiagnosisComplete Health HistoryPhysical ExaminationSupplementary ExaminationDoctorMedical care and nursi

3、ngBDACNurseMeasurement of vital signsExecutive PrescriptionClinical ObservationInjectionDrugMedical care and nursingDiagnosticsComplete Health HistoryPhysical Examination（癥狀、體征）（癥狀、體征）Medical Diagnosis上感上感Nursing assessment發(fā)熱、發(fā)熱、焦慮焦慮Nursing Diagnosis體溫過高、焦慮體溫過高、焦慮01020304Orders降溫藥、抗生素降溫藥、抗生素05nursin

4、g intervention降溫、心理護理降溫、心理護理Integrated Health AssessmentGet the ability of integrated health assessment.Complete physical examination to assess correctly and accurately.Demonstrate basic methods of inspection, palpation, percussion, and auscultation.Be able to collect the medical history correctly a

5、nd effectively. Learning outcomes 0101 PART ONEInterviewThe Interviewwhat the person says about himself or herselfsubjective data what you obtain through physical examinationobjective dataThe terms of the contract includeABCIntroduction of yourselfExpectation of participationAny costs to the clientT

6、he Process of CommunicationReceivingSendinginformationInternal FactorsExternal FactorsLiking OthersEmpathyListenSelf-AwarenessEnsure PrivacyRefuse InterruptionsPhysical EnvironmentPhysical EnvironmentTemperatureTemperature and comfortableand comfortableSufficient lighting Sufficient lighting Remove

7、distraction objects or equipmentRemove distraction objects or equipmentPlace the distance between you and the client at 4 Place the distance between you and the client at 4 to 5 feet to 5 feetTechniques of CommunicationOpen-Ended QuestionsIntroducing the InterviewClosed or Direct QuestionsTen Traps

8、of Interviewing Verbal ResponsesIntroducing the Interview“Mrs. Sanchez, I would like to talk about your illness “Mrs. Sanchez, I would like to talk about your illness that caused you to come to the hospital.”that caused you to come to the hospital.”“Mr. Craig, I want to ask you some questions about

9、your “Mr. Craig, I want to ask you some questions about your previous medical history, family history, and any current previous medical history, family history, and any current complaints before we complete your physical examination.”complaints before we complete your physical examination.”“Tell me

10、how I can help you.”“Tell me how I can help you.”“What brings you to the hospital?”“What brings you to the hospital?”“You mentioned shortness of breath. Tell me more “You mentioned shortness of breath. Tell me more about that.”about that.”“How have you been feeling since your last “How have you been

11、 feeling since your last appointment?”appointment?”O(jiān)pen-Ended Questionsnarrative informationClosed or direct questions ask for specific Closed or direct questions ask for specific information. They elicit a short, one- or two-word information. They elicit a short, one- or two-word answer, a “yes” or

12、 “no,” or a forced choice.answer, a “yes” or “no,” or a forced choice.Closed or Direct Questionsspecific informationClosed or Direct QuestionsAre your headaches on one side or both?Are your headaches on one side or both?“Have you ever had pain, double “Have you ever had pain, double vision , waterin

13、gvision , watering, , or redness in the eyes?” or redness in the eyes?” “Do you exercise and follow a diet for your “Do you exercise and follow a diet for your weight?”weight?”“running off”“running off” (Appalachian mountain people) diarrheadiarrheaVerbal ResponsesThere areThere are nine nine types

14、of verbal responsestypes of verbal responses12facilitation, silence, reflection, empathy,clarificationConfrontation, interpretation, explanation, summaryTen Traps of InterviewingA pregnant woman says, A pregnant woman says, “Ive been spotting on and “Ive been spotting on and off all day, and I haven

15、t felt the baby kick. I off all day, and I havent felt the baby kick. I just know Im going to miscarry.”just know Im going to miscarry.”How would you say?Ten Traps of InterviewingClient: “I feel so lost here since they Client: “I feel so lost here since they transferred me to the medical center. My

16、transferred me to the medical center. My family lives too far away to visit, and no family lives too far away to visit, and no one here knows me or cares.”one here knows me or cares.”Response: “I care what happens to you. I Response: “I care what happens to you. I will be here all day today and for

17、the next will be here all day today and for the next 3 days. Please call if you need anything.”3 days. Please call if you need anything.” 1. Providing False Assurance or ReassuranceTen Traps of Interviewing“Dr.Compton just told me I have to have “Dr.Compton just told me I have to have surgery and th

18、at, if I dont, I wont be surgery and that, if I dont, I wont be able to get pregnant. Im just not sure. able to get pregnant. Im just not sure. What would you do?”What would you do?”“If I were you “If I were you ”2. Giving Unwanted AdviceTen Traps of Interviewing3Using Authority4Using Avoidance Lang

19、uage 6Using Professional Jargon7Talking Too Much 5Distancing 8InterruptingTen Traps of Interviewing“Why did you take so much medication?” “Why did you take so much medication?” “Why did you wait so long before coming to “Why did you wait so long before coming to the hospital if you were having chest

20、 pain?”the hospital if you were having chest pain?”“You dont smoke, do you?” “You dont smoke, do you?” “You dont ever have unprotected sex, “You dont ever have unprotected sex, correct?”correct?”10.Using Leading or Biased Questions9.Using “Why” Questions02Part TowThe Complete Health HistoryHealth Hi

21、story SequenceHealthhistoryFamily historyReview of systemsFunctional assessment or activities of daily livingBiographic dataReason for seeking carePresent health or history of present illnessPast historyBiographic DataNameNameAddressAddressphone numberphone numberage age birth datebirth dateBirthpla

22、ceBirthplaceGenderGenderMarital partner statusMarital partner statusRaceRaceethnicethnicorigin origin occupationoccupationReason for Seeking Care*A A symptomsymptom is a subjective sensation that is a subjective sensation that the person feels from the disorder. the person feels from the disorder. A

23、 A sign sign is an objective abnormality that you is an objective abnormality that you as the examiner could detect on physical as the examiner could detect on physical examination or in laboratory reportsexamination or in laboratory reportsshortness of breathemphysemaPresent Health or History of Pr

24、esent Illness“Did you notice the chest pain after shoveling snow?“Did you notice the chest pain after shoveling snow?“How long did the symptom last (duration)?“How long did the symptom last (duration)?“I was so sick I was doubled up and couldnt move”“I was so sick I was doubled up and couldnt move”D

25、oes blood in vomitus look like coffee grounds?Does blood in vomitus look like coffee grounds?Head pain(pain behind the eyes).Head pain(pain behind the eyes).What makes the pain worse? Is it aggravated by weather, What makes the pain worse? Is it aggravated by weather, activity, food, medication?acti

26、vity, food, medication?Is this primary symptom associated with any others (e.g., Is this primary symptom associated with any others (e.g., urinary frequency and burning associated with fever and urinary frequency and burning associated with fever and chills)?chills)?How has this affected you? Is the

27、re anything you cant do How has this affected you? Is there anything you cant do now that you could do before?”now that you could do before?”Present Health or History of Present Illness *0705060804010203Associated FactorsSettingAggravating Relieving FactorsPatients PerceptionTimingLocationCharacterQ

28、ualityQuantitySeverityPast HealthObstetric HistoryObstetric HistoryImmunizationsImmunizationsLast Examination DateLast Examination DateAllergiesAllergiesCurrent MedicationsCurrent MedicationsChildhood IllnessesChildhood IllnessesAccidents or InjuriesAccidents or InjuriesSerious or Chronic Serious or

29、 Chronic IllnessesIllnessesHospitalizationsHospitalizationsOperationsOperationsRecorded as:Grav 3Term 2Preterm 1Ab 0Living 3Current Medicationsname (generic or trade), dose, and schedulename (generic or trade), dose, and schedule“How often do you take it each day? What “How often do you take it each

30、 day? What is it for? How long have you been taking it? is it for? How long have you been taking it? Do you have any side effects?” Do you have any side effects?” if not taking it, “What is the reason you if not taking it, “What is the reason you stopped taking it?”stopped taking it?”Health History

31、SequenceHealthhistoryFamily historyReview of systemsFunctional assessment or activities of daily livingBiographic dataReason for seeking carePresent health or history of present illnessPast historyFunctional assessment or activities of daily livingADLs bathing, dressing, toileting, eating, walking;

32、Functional assessmentorganizing the entire assessment around functional “pattern areas.”11 Instruments that emphasize functional categories may help to lead to a nursing diagnosisFunctional health patterns , FHPSSelf-Esteem, Self-Esteem, Self-Concept Self-Concept ( (自我概念型態(tài)自我概念型態(tài)) ) Activity/Exercise

33、Activity/Exercise（活動與運動型態(tài)）（活動與運動型態(tài)） Sleep/RestSleep/Rest（睡眠與休息型態(tài)）（睡眠與休息型態(tài)）Nutrition/EliminationNutrition/Elimination（營養(yǎng)與代謝型態(tài)）（營養(yǎng)與代謝型態(tài)）Interpersonal Interpersonal Relationships/ResourcesRelationships/Resources（角色與關(guān)系（角色與關(guān)系型態(tài)）型態(tài)）Spiritual Spiritual ResourcesResources（價值與信念型態(tài)）（價值與信念型態(tài)）Coping and Stress Coping and Stress ManagementManagement（壓力與壓力應(yīng)對型態(tài)）（壓力與壓力應(yīng)對型態(tài)）Personal Personal HabitsHabitsEnvironment/